extensive urinary extravasation and large retroperitoneal hematoma
其它影像学检查Imagings studies
平片Plain film Obliteration of the psoas shadow----retroperitoneal hematoma or urinary extravasation Bowel gas Transverse vertebral process fractures or rib fracture
red blood cells per high-power field [RBC/HPF] or positive dipstick finding) or gross hematuria is characteristic.
Hematocrit: normal initially, drop when presistent bleeding
重型肾裂伤
血压、血稳尿定、血常继规续非手术治疗 非手术治检疗查、局部肿块等情
况是否好不转稳定 手术治疗
肾粉碎伤
手术探查
肾盂破裂
肾不显影 （肾蒂伤？）
手术治疗 肾动脉造影
手术探查
远期并发症的处理
肾周脓肿必须引流Perinephric abscess should be drained
肾性高血压:血管重建 vascular reconstruction or 肾 切nephrectomy
影像学检查：增加CT首选
Helpful in assessing the extent of renal injury The preferred imaging study for renal trauma is contrast-enhanced CT.
♫highly sensitive ♫ highly specific
挫伤Contusion: Microscopic or gross hematuria, urologic studies normal
Ⅱ度（血肿）
血肿Hematoma: Subcapsular, nonexpanding without parenchymal laceration
Hematoma: Nonexpanding perirenal hematoma
原因Cause of Bladder Injury
直接暴力Most bladder injuries --blunt force to a full bladder
骨盆骨折15% in pelvic fracture 盆腔手术Pelvic surgery 膀胱镜Cystoscopic maneuvers 尿道扩张Urethral Dilation
Sonography is being used with greater frequency in the immediate evaluation of injuries.
It confirms the presence of two kidneys and can easily define any retroperitoneal hematoma.
并发症 Complications
尿瘘Urinary fistula 输尿管梗阻Ureteral obstruction 肾积水Hydronephrosis 感染Renal infection 腹膜炎Peritonitis 尿毒症Uremia
治疗Treatment
Ureteral division
术中早期发现的处理
Early reoperation
膀胱瓣Psoas hitch or Boari flap 回肠代Intestinal ureter
经皮肾引流Percutaneous nephrostomy 修补Definitive repair 肾切除Nephrectomy
膀胱损伤 Bladder Trauma
维持血容量 抗感染 密切观察
手术治疗
开放性损伤几乎全部需要手术 闭合性损伤的处理流程
肾损伤 闭合损伤处理流程
稳
镜下血伤昏后迷有、定无恶休心克、、呕尿吐等 不大稳剂
闭
定
量
合
静
性
脉
肾
尿
损 伤肉
眼
稳 定
路 造 影
血 尿
有无休克
不 稳 定
纠 正 休
克
非手术治疗
肾挫伤或轻 型肾裂伤
非手术治疗
概述 病理
短时间内
泌
出血
大量出血
尿
系 统
血肿
损
压迫 梗阻
伤
尿外渗
继发 感染
休克
脓肿 脓毒症
尿瘘 尿道狭窄 输尿管梗阻
肾损伤 Renal Injury
病因 开放性损伤 闭合性损伤
直接暴力损伤 间接暴力损伤
自发性肾破裂 医源性损伤
肾损伤 病因和病理
肾损伤分类： Ⅰ度 （小挫伤）
肾损伤并发症
近期并发症
腹膜后尿性囊肿 感染、脓肿
远期并发症
肾性高血压 肾积水 肾萎缩 肾周假性囊肿 肾盂肾炎 肾结石
肾损伤治疗
紧急治疗：着重于休克的防治 非手术治疗
绝对卧床
• 病例讨论：肾损伤后卧床一周，血尿消失的患者， 返家后再次出血，终致肾切除，为什么？
肾损伤的诊断
病史（致伤原因）→ 非常重要 临床表现 实验室检查 影像学检查
血尿Hematuria
Is the best indicator of traumatic urinary system injury.
However, the degree of hematuria and the severity of the renal injury do not correlate consistently.
诊断
病史→ 非常重要 临床表现 实验室检查 影像学检查
临床表现
侧腹和下腹疼Flank and lower abdominal pain
肾盂肾炎pyelonephritis
急性肾功能衰竭Acute renal failure or 肾积水 hydronephrosis
尿漏Urine leak from the wound
confined to renal retroperitoneum
Ⅲ 度（小裂伤）
裂伤Laceration: <1-cm parenchymal depth of
renal cortex without urinary extravasation
Ⅳ 度（深裂伤）
Laceration : >1-cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation
概述：尿道
浅表→男性球部骑跨伤、女性少见 损伤部位不同→尿外渗范围的不同
概述
发生频率：男性尿道>肾和膀胱>输尿管 联合伤多见，闭合性损伤为主 症状特点：血、尿、梗阻等 必须注意的医源性损伤
泌尿外科手术 针对腹腔和腹膜后其他脏器的手术 提示：一侧肾行手术，必须先了解对侧肾情况
病理Pathology
挫伤Contusion
20% OF
CARDIAC OUTPUT
(APPROX. 1200ml/min)
STRAIGHT GOES TO THE KIDNEYS
概述：输尿管
位置深、蠕动→创伤少见 行程长→易医源性损伤 症状→尿漏、梗阻、尿瘘等
概述：膀胱
充盈时易损伤、空虚时少见 腹膜内外破裂→尿外渗范围的不同
Laceration : Parenchymal laceration
extending through the renal cortex , medulla, and collecting system
Ⅴ度（碎裂、肾蒂损伤
Vascular:Main renal artery or vein injury with contained hemorrhage
输尿管损伤 Ureteric Trauma
特点
创伤少见Ureteric trauma is uncommon
医源性多见Iatrogenic injuries continue to occur
妇科手术Pelvic surgery 输尿管镜 Ureteroscopic Injury 放疗Radiation therapy
超声Sonography
Hydronephrosis Hydroureter Fluid mass due to urine extravasation
肾动态显像Radionuclide scanning
Delayed excretion Accumulation of counts in the pelvis and renal
其它症状Other symptoms
出血性休克Hemorrhagic shock 恶心Nausea 呕吐Vomiting 腹部肿块Abdominal distention
实验室检查Laboratory findings
Trauma-----Microscopic or gross hematuria The presence of microscopic hematuria (more than five
paranchyma----ureter obstruction Urinary extravasation
鉴别诊断 Different diagnosis